Innovative Perspective in Aging Care Open Access to Scientific and Medical Research DOI: 177286

Journal name: Clinical Interventions in Aging Article Designation: Perspectives Year: 2018 Volume: 13 Clinical Interventions in Aging Dovepress Running head verso: Gandarillas and Goswami Running head recto: Merging current health care trends: innovative perspective in aging care open access to scientific and medical research DOI: 177286

Open Access Full Text Article Perspectives Merging current health care trends: innovative perspective in aging care

Miguel Ángel Gandarillas1 Abstract: Current trends in health care delivery and management such as predictive and Nandu Goswami2,3 personalized health care incorporating information and communication technologies, home- based care, health prevention and promotion through patients’ empowerment, care coordination, 1Department of Social Psychology and Methodology, Faculty of community health networks and governance represent exciting possibilities to dramatically Psychology, Autonomous University improve health care. However, as a whole, current health care trends involve a fragmented and of Madrid, Spain; 2Physiology Division, Otto Loewi Center of scattered array of practices and uncoordinated pilot projects. The present paper describes an Vascular Biology, Immunity and innovative and integrated model incorporating and “assembling” best practices and projects Inflammation, Medical University of of new innovations into an overarching health care system that can effectively address the Graz, Graz, Austria; 3Department of Health Science, Alma Mater Europea multidimensional health care challenges related to aging patient especially with chronic health University, Maribor, Slovenia issues. The main goal of the proposed model is to address the emerging health care challenges of an aging population and stimulate improved cost-efficiency, effectiveness, and patients’ well-

For personal use only. being. The proposed home-based and community-centered Integrated Healthcare Management System may facilitate reaching the persons in their natural context, improving early detection, Video abstract and preventing illnesses. The system allows simplifying the health care institutional structures through interorganizational coordination, increasing inclusiveness and extensiveness of health care delivery. As a consequence of such coordination and integration, future merging efforts of current health care approaches may provide feasible solutions that result in improved cost- efficiency of health care services and simultaneously increase the quality of life, in particular, by switching the center of gravity of health delivery to a close relationship of individuals in their communities, making best use of their personal and social resources, especially effective in health delivery for aging persons with complex chronic illnesses. Keywords: health management, e-health, patient-centered health care, home-based care, health governance, community health Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 28-Dec-2018

Point your SmartPhone at the code above. If you have a Introduction QR code reader the video abstract will appear. Or use: In recent years, health care delivery has witnessed a vertiginous revolution. Informa- http://youtu.be/aTF0J65FLUE tion and communication technologies (ICT) are bringing a new reality, allowing for powerful means of processing a variety of data about many individuals in different environments. This is facilitating the development of fresh and more effective approaches to prevention and treatment not possible just a few years ago. This rapid development of ICT brings new advantages but new challenges as well. On the posi-

Correspondence: Nandu Goswami tive side, ICT tools are allowing more autonomy and quality of life for patients and Physiology Division, Otto Loewi Center improving cost-efficiency of health centers, promoting a new culture of interagency col- of Vascular Biology, Immunity and laboration and public participation. This may especially benefit patients with complex, Inflammation, Medical University of Graz, Neue Stiftingtalstrasse 6, D-5, A-8010 multidimensional problems and comorbidities, as often occurs in many cases of older Graz, Austria people with chronic diseases (CD).1 On the negative side, home-based ICT may pose Tel +43 316 3857 3852 Email [email protected] new challenges for both the patient and the health care service. For the patient, such

submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2018:13 2083–2095 2083 Dovepress © 2018 Gandarillas and Goswami. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you http://dx.doi.org/10.2147/CIA.S177286 hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).

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challenges can include increased dependence on their health and many of these dependency-related problems thus increase center, false expectations of protection, difficulties managing the occurrence of possible comorbidities.16,17 This implies the technology, increased isolation, excessive feelings of higher need for dependency-related complex care. Unsur- responsibility and blame, and false alarms created by disease prisingly, CD are currently the main cause of dependency predictions. For the health care services, challenges can of the aging population in developed countries. The data on include difficulties in data protection, an overwhelming flow CD clearly points out the need to improve early detection of of data, and the need for new human resources, training, and CD and preventive care using multilevel approaches. organizational structures.2–8 New ICT will not be maximally effective by just adapting the traditional health care systems Current trends in health care innovation for the to incorporate such tools. Such an introduction of a new ICT aging CD patient may represent more problems than advantages. We need to Traditional illness-centered health care models fall short move forward toward novel health care approaches that are when facing the CD challenges in our increasing aging capable of making the best use of the potentials of new ICT population. As the World Health Organization already along with the development of current trends. Current trends, challenged the traditional view in its definition of health in approaches, and paradigms such as those pointed below are 1948, nowadays health care trends try to go further. Some implemented in a myriad of scattered practices that need to authors18 propose to define health as “the ability to adapt and be analyzed, incorporating the emerging tools and methods to self-manage”, reflecting the current reality of older chronic into solid systems. patients. Current trends try to make health services more The aim of the present work was to suggest feasible effective by being personalized and tailored to the patients’ ways of incorporating these practices into a general model needs, resources, and characteristics, based on early detection of advancement and innovation in health care delivery and of risks and preventive treatment in the person’s environment. management. New ICT tools for ambulatory care are strongly contributing to the feasibility of home-based health care even in serious For personal use only. Challenges and opportunities in current cases which just some years ago were restricted to intensive health care trends of chronic diseases care units in hospitals.19,20 But the application of these insights The rising prevalence of chronic diseases is hampered by the fragmentation of services in most health As people live longer, CD (such as chronic cardiovascular systems.21–23 The latest health care approaches are stressing diseases, arthritis, osteoporosis, diabetes, hypertension, neu- the need to advance new frameworks for collaboration among rodegenerative disorders, severe psychiatric illnesses, chronic social and health services in order to address the complex respiratory disorders, severe chronic pain problems, and nature of CD progression in the older person, including bio- dementia) are increasing in their relative prevalence when logical, physiological, psychological, social, and contextual compared with other types of illnesses and are currently factors (eg, de Bruin et al and Burns et al24,25). Current health the leading causes of deaths in many countries, especially care trends do recognize such challenges and are progressing Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 28-Dec-2018 striking the aging population (eg, 75% of the population may towards attaining the desired integration of health elements die from CD in developed countries in the near future9–12).11 and services. A bibliographic review of evaluative research The multidimensionality of CD in the elderly is of particular on innovative practices in the field allowed us to group them importance, with different aggravating factors appearing in the following current trends: together with general deterioration of physical and cogni- 1. Early diagnosis and prevention,25,26 facilitated by new ICT tive abilities, such as increased risk of falls, fractures, and tools.27–33 Multidimensional systems include noninvasive disabilities; comorbid neurological and cerebrovascular monitoring tools, gathering relevant patient’s biopsycho- disorders; nutritional deterioration; abuse of polypharmacy social information within predictive applications to be and self-medication; severe confusion syndrome; losses in used by the patients and health centers. E-health systems basic life activities; emotional stress; difficulties associated incorporate and process large amounts of real-time, with acceptance and compliance of treatment; deprivation multidimensional information from/to the patients’ home of social support; reduced income; increased stigma and and natural settings, and from/to different areas and agen- discrimination; reduced access to health and social services; cies in shared, interoperable, and synched big databases physical and psychological abuse and neglect.11–16 There is a using cloud computing technology.5,19,20,33 Information bi-directionality in the relationship between chronic disorders recording and processing applications for smart wearable

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technologies (SWT), depth cameras, and knowledge patients in a local area, promoting health communities management (KM) tools are more and more used in (groups of patients with similar illness organizing smartphones, tablets, and computers, including real-time themselves in mutual-support communities) intertwined information gathering and sharing tools, and patients and with the local community, and enhancing personal and corporate portals for information interfaces and com- social resources on health and well-being to increase munity participation. An ICT-supported KM approach self-competence, cognitive and social skills, physical may include collective intelligence processes, informa- autonomy, illness acceptance, treatment compliance, and tion-shared analysis, planning problem–solving, and proactive involvement of the patient, that is, empowering actions to promote health and well-being, follow-up, the patient.1 Current examples in this direction are the and accountability.31–33 SWT, a noninvasive technol- home and community care managers, and even nonhealth ogy for remote, unobtrusive, and real-time recording professionals after a training program, significantly con- of physiological data (heart rate, blood pressure, skin tributing to reduce dependency and improve quality of conductance, respiratory rate and volume, movement, life in older patients.37 and blood glucose) virtually without discomfort, allows 4. Genetic, psychosocial and real-time physiological a person to carry out their habitual daily activities while predictive tools and algorithms regarding the patients’ being monitored and guarded in their natural context.33 health. Such tools and algorithms can be used for early This technology opens tremendous possibilities for early detection, screening, and overarching preventive diag- detection and prevention of disease progression, relapses, nosis, and can incorporate mathematical and statistical and crises through the development of predictive tools models.17,27–33,38–43 including all the related biopsychosocial indices. 5. Integrated health care. This entails a set of procedures to 2. Home-based, outreach health care. This approach works merge services from different agencies and formal and in the natural context where the problems and solutions informal resources in the relationship with the individual, are most present to preserve the well-being and autonomy family, and community. This approach is intended to For personal use only. of the patient. Cost-effectiveness studies19 comparing tackle all main factors affecting a disease in a systemic inpatient care vs home care revealed that patients in their and overarching manner,19–24,33 centered on improving own environment could manage their own autonomy the coordination among services and resources and the and health longer and with higher satisfaction. More engagement of all stakeholders (including the patients sustainable health autonomy and improved quality of and their communities) in decision-making, treatment, life together with a reduction of costs by having the prevention, and health promotion.22,44 Aging persons patient at home appear to provide a more cost-efficient with CD are perhaps the best example of cases with approach than in-patient centralized care.19,20 Providing multifaceted and multilayered problems needing such home-based services appears to improve symptoms; a multidimensional approach to their care.24 Current saves costs to health services; reduces hospitalization; integrated approaches include the following types of Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 28-Dec-2018 preserves patients’ preferences, autonomy, and medica- practices: tion adherence; increases practitioners’ satisfaction; and i. Health care e-governance. The deployment of an makes better use of psychosocial support.1,34,35 Good organized health umbrella allows gathering and examples are the home-based reablement (intense reha- optimizing all formal services and informal resources bilitation) practices, successfully expanded in different (such as social capital), seeking mutual support countries.36 and collaboration, and avoiding the fragmentation 3. Psychosocial health promotion, centered on the patients’ of service provision, overlaps among services, and personal and social resources. The World Health Organi- social pockets of underserved groups in dire need.23 zation16 points out the need to include community health In particular, CD patients, who are more vulnerable promotion strategies in health care systems. Searching for to psychosocial stressors, may show a poor ability increased cost-efficiency and effectiveness, health care to use health resources due to well-known processes should enhance psychosocial resources of the patient and such as the Inverse Care Law (the higher the need for their communities. Community health managers (those health or social services the less available they will agents in charge of the general health in a local com- be), the Matthew effect (people with more resources munity) represent a fundamental avenue for reaching all will have higher probability to access to health or

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social services), learned helplessness, and poor self- which is especially important in CD cases due to efficacy.45–47 This represents a challenge that requires the special need of these patients to preserve their the coordinating effort of all different agencies. Health autonomy and to prevent helplessness. information technology poses opportunities and chal- iv. Palliative care. Preserving the quality of life and well- lenges to improve not only horizontal but also vertical being of the patient is currently regarded as a need health governance (between patients’, managers’, and and a right of advanced CD patients, allowing both political levels of care coordination) as the greater quality of life and ability to face death with dignity. information flow among levels may need a further Whereas palliative care has undergone an exponential effort in information management.48 However, health growth in the last decades, still only a small percent- institutions still find it difficult to acquire the needed age of patients with advanced CD receives it. This is coordination with other agencies and services (such mainly due to organizational and budget difficulties as education, social services, economy, housing, and of public health services in organizing the multi- environmental services) at local and national levels.21 agency and home-based services that palliative care In some cases, care coordination has not exhibited requires.12,19–21 clear benefits in terms of cost-efficiency, while bring- v. Shared health care models. A collaborative work of ing more complexity and requiring greater effort in health practitioners and patients is frequently carried human resources.48 This could be due to a poor culture out through a one-stop service directly related to the of interagency team work but also could be due to a patients. Shared management is commonly personal- lack of experience in or ability to change and adapt ized and very effective, as it is relatively easier and within each organization. Deploying health care gov- simpler to implement.20,33,44,51,52 ernance models does not have much meaning if they Current research exhibits the effectiveness of patient- do not bring along a structural simplification of each centered, home- and community-based integrated manage- participant organization in health care delivery and ment models that are based on e-health governance and For personal use only. management. Besides, even though, currently there is prevention/promotion approaches, tackling all main factors a general agreement that informal resources and social affecting a disease in a systematic approach compared with capital are fundamental for patients’ empowerment, traditional inpatient and specialized treatments (eg, Labson their actual integration with formal health care man- et al, Luckett et al, Lehtinen et al19,20,53). This is being facili- agement is still limited in most countries.21–23 There tated by current ICT/KM tools allowing mathematical and is a need to stress proactive health care management statistical methods to process large amounts of data on the to engage and integrate all members of the commu- patients’ organic systems and their relationship with the nity in the health system, to improve cost-efficiency, individual’s psychological and social environmental context effectiveness, and quality of services.23 to predict general health dynamics, embedded in a work ii. Patient-centered, home- and community-based man- philosophy of stakeholders’ proactive collaboration. Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 28-Dec-2018 agement models. Intraorganizational simplification in Despite the exciting perspectives opened by these structures and processes, decentralization of services, trends, most innovative practices are represented by pilot participatory health value chains, and interorganiza- experiences, excessively fragmented, partially scattered, tional development are achieved by centering services not linked to a broader context, and not easily transferable in the relationship with the patients in their home and or scalable.21,22 This chaotic variety of experiences results community12,19,20,49–52 with the support of interoperable in poor agreement among public health institutions and ITC/KM systems.33 systems on what methodologies are best to follow.23 A fun- iii. Self-management health models. These are aimed at damental challenge of current health care approaches is the strengthening individual and community empower- need for developing unified care management and delivery ment in health self-care and increasing the perception frameworks.22,23,44,54 Current directions in health care are of self-efficacy and control over personal health. The aimed at finding greater agreement regarding the best com- experience based on these approaches3,6 applied to CD bination of health care promotion, prevention and treatment will provide the basis from which to move forward strategies and tools. Furthermore, real tailored, community- from the dependency-ridden traditional health care and person-centered health care systems should be capable models to a more balanced comanagement of health, of adapting to any type of cultural, social, and institutional

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conditions. Social diversity is universal, so the experiences An effective IHMS approach applied to the aging CD of adapting the health systems to a diverse society should patient is centered in the diverse society, using latest technol- render more agreement in the methods. The ability of health ogy for personalized health, optimizing the balance between systems to have flexible methods adaptable to any social cost-efficiency, effectiveness, and patients’ well-being. condition is especially needed when facing the multifaceted Such an IHMS is intended to be adaptable to any social and nature of most CDs. geographical context. The key components of the IHMS are Following these aims, a proposal for an integrated health grouped into four basic areas: 1) home-based and community- care management system (IHMS) to apply to CD in the older centered health care delivery, 2) health care governance, population is outlined here, based on an effort to combine the and 3) latest ICT/KM tools on home-based monitoring and most successful current trends. This system articulates the prediction, and 4) Y-relational health care management. collaboration among institutions, practitioners, experts, and users, to provide a feasible and effective transdisciplinary Home-based and community-centered health care health care delivery and management for the CD patient, Person-centered health care implies pinpointing all the including risk detection, prevention, and treatment to improve uniqueness and differential characteristics of each patient cost-effectiveness of services and quality of life in the aging and their context in order to personalize health diagnosis, CD population. treatment, prevention, and health promotion. Person-centered health care entails distinguishing the entwined system of Proposed methodology: positive and negative elements around patients and integrat- incorporating current trends into an ing all the resources in the direct relationship with them. innovative system centered on the Shared health care sends the message to the patient that we are “counting on you”. “Full” patient involvement in the aging patient with chronic disease cocreation and comanagement of health care brings the pos- Target groups sibility of a joint, deliberate, thoughtful, advised, informed, For personal use only. The proposed IHMS outlined in this section focuses on the discussed, and mutually agreed upon type of health care that most frequent types of CD developing into serious depen- is desired and needed, especially useful on aging chronic dency in the aging population, as they imply the highest patients. 1,9–14,16 challenges in health care services: oncologic illness, In order to tailor the health system to the diverse soci- pulmonary chronic illness, cardiac chronic illness, neurologic ety that we live in, the two most significant contexts of the diseases, diabetes, severe hepatic illness, and dementia/ patients, their home and community, should be the focus of psychiatric disorders. Health managers and practitioners health care. Home and community do not only refer to physi- and those of other participant agencies (social services, cal places but represent a unique biopsychosocial ecosystem education, housing, economy, etc.), informal caregivers, and constituting the person’s habitat. Reaching the person in their community members are also viewed as participants in the context means deeply understanding, caring, and using the Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 28-Dec-2018 overall health care system, contributing in all the stages of the patients’ resources as a powerful strategy for effective and system deployment process (system design and deployment, cost-efficient health care. It facilitates tackling the negative training, monitoring, evaluation, and dissemination). contextual factors affecting the patient and enhancing the positive factors for individual and community empowerment, System design procedure proactive health promotion, and wellness. This is especially Health care delivery to the aging CD patient should encom- true when facing CD, with frequent etiologies, risks, and pass a large set of interrelated social, environmental, psy- vulnerabilities in their environments and with solutions chological, genetic, and physiological features, tackling all within the formal and informal resources in their communi- these different factors with holistic, systemic approaches. The ties. Home- and community-centered health care also brings system here presented was designed by taking into account a better relational management approach, fundamental when evidence-based successful innovative practices from differ- care is aimed at following the evolution of the disease for an ent countries. The designed system proposed here has been optimal quality of life in a supporting and close relationship developed by incorporating different disciplines (medical with the patients, caregivers, and their communities. Health specialties, psychology, sociology, public management, care methods adapted to a diverse society further enables policy-making, computer scientists, and engineering). transferability to other territories, as it should be free of

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social, cultural, and institutional biases. An approach based on a diverse society entails universal values that bring an &KURQLF opportunity to exchange experiences and to establish local GLVHDVH and international collaborations based on the common goal FRPPXQLW\ of reaching all persons in need of services to guarantee social inclusion in the health system.

6RFLDO /RFDO $JLQJFKURQLF Health care e-governance VXSSRUW FRPPXQLW\ GLVHDVHSDWLHQW A good health care governance model should be able to coor- QHWZRUNV dinate, systematize, and standardize procedures and protocols of information exchanging, sharing, processing, decision- making, planning, and intervention in order to adapt them to different contexts in a joint work among local, national, and international agencies. The horizontal and proactive +HDOWKFDUH FRPPXQLW\WHDPV joint work among health departments, social services, education, housing, environmental services, NGOs, along with the (local and health) communities and patients will enable Figure 1 Nested communities in personalized, relational health care management tackling more effectively different factors affecting health, centered on the patient. with better inclusiveness (reaching those most excluded from Note: The health management system is aimed at enhancing mutual support among the patients’ social support, the chronic disease group (promoted as health the health system) and extensiveness (reaching all the people community), the local community (neighborhood), and the health care teams. with CD or with risk of CD). Overarching health care based on an integrated analysis of biopsychosocial risk as well as protective factors will allow for implementation of collec- The most common e-health recording devices monitor For personal use only. tive intelligence and KM processes in health management, discrete physiological indices (heart rate, blood pressure, and contributing to more accurate diagnoses of health-related respiratory measures) at specific regular moments which do problems, defining proper and desired care strategies, rede- not allow for synchronization and the analysis of the dynamic signing treatment programs, and monitoring them in order to relationship among indices across time. Continuous (second prevent and treat CD. We also need to seize the opportunity by second) analyses of the relationship among indices provide to work toward new “intercommunity” systems supported by more complete information of physiological patterns react- interoperable ICT/KM tools, while addressing the challenge ing to the persons’ stimuli, behavior, context, activities, and of maintaining data protection and confidentiality in each situations. Such an analysis allows for real-time comparisons location. The intercommunity approach may foster “nested” with previously processed information from the patient (on health communities promoting the integration between health crises and relapses) as well as comparison with analog patterns Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 28-Dec-2018 and “overlapping” local communities, by sharing social capi- from different groups with similar or even different illnesses, tal and networks into health promotion and care (Figure 1). facilitating the predictive accuracy of early detection and rapid response to health crises or relapses. Algorithms integrating ICT/KM systems physiological, behavioral, and postural information from depth Health e-governance within integrated health care approaches cameras may also be included to provide a more complete are intended to make the best use of all knowledge resources overview for monitoring patient status and service delivery. available and to share them among stakeholders, patients, Patients’ biopsychosocial predicting profiles may include and communities, using social capital for an effective plan- genetic, physical, and physiological indices, behavioral hab- ning to solve problems. New ICTs/KM tools address these its and activities, emotional changes, social and economic goals as they make it possible to monitor individuals in their features, subjective well-being, quality of life indices, and natural context, processing interdimensional information disability scales. Many of these indices may be self-recorded and developing analytics to be included in software applica- by the patient in a mobile device, with indicators of well- tions in order to better understand and predict CD progress being based on standard scales such as Satisfaction With Life and relapses. Thus, the result improves patient care, patient Scale (SWLS), General Self-Efficacy Scale (GSES), Short autonomy, and operational efficiency.33 Form Health Survey (SF-36), and World Health Organization

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Disability Assessment Schedule (WHODAS) 2.0 as additional in interaction with adaptation mechanisms. Algorithms procedures for the effectiveness evaluation. Easy-to-use fea- are defined based on noninvasive physiological record- tures will allow the patient to have access to the information at ing to study and predict changes in the balance between any time with explanations and recommendations. Automatic resilience and adaptation. integration of collected between- and within-subject data in 2. Statistical approach: Based on interdisciplinary ontolo- databases can provide the medical and research communities gies, cross-fertilization of methods and processes with with an opportunity to assess effectiveness, enabling insights other disciplines (eg, meteorology) may lead to new into illness evolution, the effects of drug therapy, treatment approaches for medical diagnosis and prediction. For compliance, and rehabilitation process. Acceptance by the instance, weather forecast provides a useful analogy patient is reinforced by developing friendly and useful appli- for the dynamics of human physiology. Earth’s weather cations. Furthermore, specific acceptance strategies of the also represents a unit governed by a system of inter- e-health system may be developed through cocreation with related forces. Some ecological approaches understand the end user. In addition, the system may be integrated with the Earth’s surface as a “living system”. Mathematical microelectromechanical systems for the automatic delivery (linear and nonlinear) dynamical models are not as use- of drugs, making it compatible with regular Android and ful in weather forecasting as statistical methods using Apple smartphones, mobile and electronic companies, and multivariate tools, with increasing accuracy (eg, see with new protocols and services of data transmission, pro- Bellone et al, Enke and Spekat, Gardner and Dorling, cessing, storing, and protection (eg, HL7 Personal Health and Cofiño et al55–58). These methods use past data from Monitoring Standard), thereby ensuring easy adaptability to several indices across time and space to predict future most ambulatory recording devices already available in the “analog” weather conditions. Meteorologists have taken health services where the system is deployed. advantage of the speedy evolution of computer power to Training should be provided to formal and informal include more and more data from more variables, combin- health care givers regarding assisting the patient in learning “machine-learning” methods with dynamic models, For personal use only. ing how to best use the system. The multidimensional data intending to get the “whole picture” (eg, “Bayesian recording and processing capability will also allow for a Networks”58). The potential cross-fertilization may be continuous evaluation of the system performance in terms useful when addressing how to predict the influence of cost-efficiency and effectiveness regarding reduction of multiple (genetic, physiological, and psychosocial) in patient hospitalizations, preservation of autonomy and factors in physiological activity.41 cognitive functions, quality of life, functional capacity, self- ICT will also allow deeper decentralization and deconcen- monitoring ability, safety, comfort, cost-efficiency, treatment tration of information analysis and decision-making, which compliance, technical usability, and acceptance. Integrating can enhance strategies of data protection and confidentially. genetic, physiological, psychological, and social information It is more difficult for a hacker to attack a “neural network” of the patient will allow for a more accurate, comprehensive, than a server where all information is centralized. “Big data” Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 28-Dec-2018 and interdisciplinary diagnosis, monitoring, and prevention. distributed systems may allow us to imitate our brain (as a To do so, predictive software applications are included in knowledge network) as a sound strategy for data protection the system based on a combination of mathematical and and effective management. statistical approaches: Information processing and management. Data stored in 1. Mathematical approach: This quantifies the observation the local IHMS Data Banks can be connected together to form that the characteristics of biological processes that regu- an international IHMS Data Bank. Data can then be stored late physiological responsiveness and maintenance of on the servers and computers of the participant institutions stability are based on the patients’ genetic, physiological, and individuals gathering that information, connected via psychological, and social background.34 Physiological cloud computing technology. Methods and processes can resilience and adaptation may be represented in terms of be developed to exploit multivariate statistical analyses chaos theory as two attractors for the dynamics of physi- (including profile and trend analyses), bootstrap, mixed ological regulation. Resilience mechanisms are suggested models, optimal scaling (multiset canonical correlation), and to help to protect an organism from short-term system cluster analyses. All these aspects can be used to integrate, perturbations and long-term overadaptation and to bal- cross-classify, and organize information and study predictive ance biological, psychological, and social arousing effects relationships (eg, regressions), differences across systems

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(eg, multivariate analyses of variance), and patterns among knowledge reflecting their needs and problems and solutions. variables and indicators (eg, cluster and analog analyses), This way, health organizations may be able to implement combined with qualitative information (based on interviews integrated and interagency plans, with horizontal and verti- and group dynamics on analyses of problems, definitions cal interoperable coordination procedures among services. of solutions, and decision-making on actions to be taken). This will facilitate further simplification of organizational Patients’ biopsychosocial patterns will be compared with structures and processes. A Y-relational management model analog patterns of patients with different diseases in order is included here, with features such as integrated interagency to set probabilities of diseases and crisis. services centered on the patient, collaborative leaderships, intercommunity nested social networks, health self-manage- Relational management approach ment tools, shared capital resources, new computer applica- A relational management approach is used to integrate tions for information recording and processing in ambulatory resources and services in the relationship with the person in care, and integrated management processes (Figure 2). the community. The desire for a real overarching, multimodal, The system should include different data collection meth- and integrated management system centered on the person ods: surveys, qualitative and quantitative techniques, and is shared by most practitioners from health and education participatory-action research with home visits, and patients’ agencies, social, employment, and environmental services, and community portals with smartphone apps coordinating and general public managers. The IHMS uses participatory the work of health practitioners and those from other dif- methods to gather and process sufficient and meaningful ferent agencies participating within the community. This information from all stakeholders, for the cocreation of new system will enable agencies and patients to share different For personal use only.

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Figure 2 Y-relational health care management. Note: The management system integrates all (formal and informal) resources and services in the relationship with and between the patient, the disease groups (being promoted as health communities), and the local community.

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fields of information with other agencies and users for KM, Formal and informal resources are integrated in the rela- but without sharing fields that such other agencies, patients, tionship between a community health care manager (CHM) and outside users do not need. This requires management of and the patients. This proposed CHM (similar to the above- confidentiality with access filters applied to different fields mentioned home and community care managers37) will be the depending on the services, agencies, and users. A main strat- person from the public health system in charge of the general egy is based on the “neural” distribution of information fields health in the community, providing community health ser- in each database in the servers of the different agencies who vices with tasks such as general community health analyses own that information, integrating it not by physical centers (including the relationship among causal, symptomatic, but in the peripheral devices of the users. consequential, and mediating factors related to health and illness), detection of individuals and groups with risks and System structure and processes vulnerabilities, referrals to the community health center, map- The four areas described above set up the framework of the ping of formal and informal resources, as well as planning of IHMS structure and processes. The structure implies a turn- actions with all stakeholders in the community. around of the traditional organizational charts of health care The CHM will horizontally coordinate (using collabora- services, placing the “nested” local-health communities at tive leadership approaches) an interagency community team the top of the chart. The services are centered on the territory (health, social, educational, environmental, housing, and where the needs and resources are most found. The general socioeconomic). Other fundamental system components in structure keeps the community-level primary and city-level the proposed IHMS will be the Health Community Council secondary in-service provision (Figure 3). (including all community members), a Health Community

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Figure 3 Structure of services of the Integrated Healthcare Management System. Notes: A neighborhood level of primary health management includes six connected bodies: a Community Health Council (composed by neighbors), a Primary Health Team (health practitioners), an Interagency Community Team (including a general community manager and community agents from different social and health agencies), a Public– Private Health Network (all public and private entities that may contribute to promote community health and well-being), a Neighborhood Health Commission (with three or four representatives of major health and social agencies, to coordinate with the city-level authorities to follow general health plans), and a Community Health Manager in charge of facilitating the coordination of all bodies for patient-centered and community-based integration of (formal and informal) health resources and services.

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Network of public and private entities, the current primary will keep the same functions, but with a closer relationship health teams, and the current health teams specialized in with the CHM. The CHM will neither carry out any medical each disease, who will work the cases as a secondary city diagnoses, nor refer a new case to a medical specialist (which level of service provision. All these elements will also work will be done by the primary medical practitioner). directly with the patient, so the first contact of the system The incorporation of ICT is a fundamental element of with a CD patient or a person with risk of chronic disease the system. Figure 4 outlines the communication system and will not necessarily be done by the CHM. The CHM does Figure 5 makes concrete the system organizational process not replace the role of the primary or general physician, who and pathways.

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Figure 4 Schematic representation of the communication structure in each local IHMS. Notes: All stakeholders and patients have available interfaces (“Personal Health Portals”) in ICT devices (smartphones, tablets, and computers) to provide and receive relevant information for monitoring and early detection of increased risks of disorder outbreaks or relapses. That information can be stored and real-time updated in local data banks to provide information for symptoms detection (and urgent intervention if needed), in combination with the information from an international IHMS Data Bank for knowledge management. Abbreviations: ICT, Information and communication technologies; IHMS, Integrated Healthcare Management System.

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System evaluation improve health care delivery as well as to enhance prevention The system is assessed using a scientific approach reflect- of CD in geriatric settings. Future developments will certainly Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 28-Dec-2018 ing 1) the effectiveness and cost-efficiency of the health strengthen the collaboration between health institutions, care management provided by a particular system; 2) the researchers, companies, practitioners, community members, predictive effectiveness of the incorporated early detection and patients regarding the sharing of effective approaches to tools, and 3) the efficiency and accuracy of methodology tackle the multicausal factors affecting CD, identifying the used to evaluate and monitor the degree of impact of system best uses of the latest ICT to address these factors. performance and its consequences regarding a disease treat- This paper highlights the great potential that can be ment and the improvement in the patients’ well-being. The realized by merging these trends and incorporating the best evaluation methodology may use the same multidimensional evidence-based tools and practices into an integrated health and interdisciplinary approach that is currently used in the care system focused on prediction, prevention, and promo- disease diagnosis, monitoring, and follow-up. tion of health within the patients’ ecosystem. Innovative e-health governance approaches will bring new revolutions Conclusion and challenges in furthering prevention, care, and quality of life, especially Current trends in health care pave the way for overarching in geriatric patients with CD. With new advances, new community- and home-based health management systems. ethical dilemmas need to be addressed; for example, how They aim at exploiting the effectiveness and cost-efficiency to use different predictive probabilities in the best way for of ICT-supported management and governance approaches to adequate prevention, or how to guarantee data protection

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and confidentiality. In this paper we described a feasible 7. Haluza D, Jungwirth D. ICT and the future of health care: aspects of health promotion. Int J Med Inform. 2015;84(1):48–57. system that may overcome current limitations in e-health, for 8. Dang S. Telemedicine applications in geriatrics. In: Fillit H, Rockwood K, example, by guaranteeing that each stakeholder has access Young JB, editors. Brocklehurst’s Textbook of Geriatric Medicine and only to the information needed by their tasks. In addition, Gerontology. New York: Elsevier Ltd; 2010:1064–1069. 9. Murtagh FE, Bausewein C, Verne J, Groeneveld EI, Kaloki YE, the potential misuse of predicting devices (for instance, Higginson IJ. How many people need palliative care? A study devel- raising alarms in the patient) could be reduced by the closer oping and comparing methods for population-based estimates. Palliat Med. 2014;28(1):49–58. face-to-face relationship of that health community managers 10. Vega T, Arrieta E, Lozano JE, et al. Atención sanitaria paliativa y de and teams with the patient. Another concern typically facing soporte de los equipos de atención primaria en el domicilio [Pallia- new healthcare structures is whether the proposed system tive health care and support services of primary home care]. Gaceta Sanitaria. 2011;25(3):205–210. Spanish. is going to incur more costs and complexity for the health 11. Gómez-Batiste X, Martínez-Muñoz M, Blay C, Ambls J, Vila L, administration. However, the governance approach used Costa X. Identificación de personas con enfermedades crónicas avanza- das y necesidad de atención paliativa en servicios sanitarios y sociales: here allows territory-based, overarching health care plan- elaboración del instrumento NECPAL CCOMS-ICO© [Detection of ning, allowing best use and synergies among formal and advanced chronic diseases and need of palliative social and health informal resources, simplifying the structure of services and services: Elaboration of the NECPAL CCOMS-ICO instrument©]. Medicina Clínica. 2013;140(6):241–245. Spanish. bringing a more cost-efficient and effective health care value 12. Beernaert K, Deliens L, de Vleminck A, et al. Early identification of chain with the participation of all stakeholders, patients, and palliative care needs by family physicians: a qualitative study of barriers and facilitators from the perspective of family physicians, community communities. To do so, horizontal and vertical collaborative nurses, and patients. Palliat Med. 2014;28(6):480–490. protocols should be clearly defined. 13. Reynolds CF, Alexopoulos GS, Katz IR, Lebowitz BD. Chronic depression in the elderly. Drugs Aging. 2001;18(7):507–514. 14. Charney DS, Reynolds CF, Lewis L, et al. Depression and Bipolar Support Acknowledgment Alliance consensus statement on the unmet needs in diagnosis and treatment We thank Dr Jerry Joseph Batzel, Institute of Physiology, of mood disorders in late life. Arch Gen Psychiatry. 2003;60(7):664. 15. Kemp AH, Arias JA, Fisher Z. Social ties, health and wellbeing: a Medical University of Graz, Austria, for his constructive literature review and model. In: Ibanez A, Sedeno L, Garcia AM, comments and his insights during the preparation of the editors. Neuroscience and Social Science. New York: Springer; 2017: For personal use only. 397–427. manuscript. 16. WHO. World Report on Ageing and Health. Geneva, Switzerland: World Health Organization; 2015. 17. Brown EG, Gallagher S, Creaven AM. Loneliness and acute stress Author contributions reactivity: a systematic review of psychophysiological studies. All authors contributed toward data analysis, drafting and Psychophysiology. 2018;55(5):e13031. revising the paper and agree to be accountable for all aspects 18. Huber M, Knottnerus JA, Green L, et al. How should we define health? Br Med J. 2011;343(Jul 26 2):d4163. of the work. 19. Labson MC, Sacco MM, Weissman DE, Gornet B, Stuart B. Innova- tive models of home-based palliative care. Cleve Clin J Med. 2013;80 Electronic Suppl 1:eS30–eS35. Disclosure 20. Luckett T, Phillips J, Agar M, Virdun C, Green A, Davidson PM. Ele- The authors report no conflicts of interest in this work. ments of effective palliative care models: a rapid review. BMC Health Serv Res. 2014;14(1):136.

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